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Incorporating Social and Behavioral Determinants
of Health in Patient Care
HIMSS Nursing Informatics PreConference, February 11, 2019
Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN, Associate Professor
The University of Alabama at Birmingham School of Nursing
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Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Introduction
• Describe national momentum towards inclusion of SDOH data
• Examine potential sources of SDOH data
• Assess strategies for incorporating SDOH data
• Review optimization strategies for the inclusion of SDOH data
• Summarize lessons learned and issues
• Solicit audience lessons
• Questions?
Agenda
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• Introduction
• Describe national momentum towards inclusion of SDOH data
• Examine potential sources of SDOH data
• Assess strategies for incorporating SDOH data
• Review optimization strategies for the inclusion of SDOH data
• Summarize lessons learned and issues
• Solicit audience lessons
• Questions?
Agenda
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• Describe the importance of social and behavioral determinants of
health to patient care
• Provide on outline for incorporating social and behavioral
determinants of health information into patient care and
documentation.
• Describe strategies for optimizing health IT systems to capture
and use information about social and behavioral determinants of
health of individuals
Learning Objectives
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• Provision 8 – The nurse collaborates with other health professionals
and the public to protect human rights, promote health diplomacy,
and reduce health disparities.
– Advances in technology, genetics, and environmental science
require robust responses from nurses working together with
other health professionals for creative solutions and
innovative approaches that are ethical, respectful of
human rights, and equitable in reducing health
disparities.
– Through community organizations and groups, nurses
educate the public, facilitate informed choice, identify
conditions and circumstances that contribute to illness,
injury, and disease, foster healthy life styles, and
participate in institutional and legislative efforts to protect
and promote health.
ANA Code of Ethics for Nurses
with Interpretive Statements
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SDOH: Contributors to Health
Creative Commons: http://www.goinvo.com/features/determinants-of-health/
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• Social factors account for 25-60 percent of deaths in the United
States in any given year according to various meta-analyses.
(Hieman & Artiga, 2015)
• Up to 70 percent of a person’s overall health is driven by these
social and environmental factors and the behaviors influenced by
them.
(Schroeder, 2007)
SDOH Impact
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Definitions of Social Behavioral Determinants of Health (SDOH)
• Complex, integrated, and overlapping social structures and
economic systems that are responsible for most health inequities.
• These determinants include social environment, physical
environment, health services, and structural and societal factors.
(CDC)
www.cdc.gov/nchhstp/socialdeterminants/definitions.html
• The conditions in which people are born, grow, live, work and age.
(WHO)
https://www.who.int/social_determinants/en/
National Momentum Towards Inclusion
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• WHO Closing the Gap in a Generation (2008)
https://www.who.int/social_determinants/final_report/csdh_finalr
eport_2008.pdf
• IOM Recommended Social and Behavioral Domains and
Measures for Electronic Health Records (2014)
http://nationalacademies.org/HMD/Activities/PublicHealth/Socia
lDeterminantsEHR.aspx
Landmark Documents
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• Federal and State Initiatives
– 2016 Center for Medicare and Medicaid (CMMI) established
by ACA announced Accountable Health Communities
connecting Medicare and Medicaid beneficiaries with
community services. CMMI awarded 32 grants.
• Medicaid Initiatives
– Delivery and payment system reform linking health care and
social needs
– Medicaid Managed Care Organizations engaging in
activities to address SDOH.
• Provider Activities
– Not for profit hospitals required to conduct community heath
needs assessments once every three years and to develop
strategies
Initiatives to Address SDOH
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What are the social determinants of health?
Income
and Income Distribution
Stress
Education
Social Exclusion
Unemployment and Job Security
Safety
Food Insecurity/Security
Domestic Violence
Housing
Incarceration
Health Services
Race
and Ethnicity
Transportation
Veteran Status
Environment
Refugee Status
World Health Organization and Institute of Medicine
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• Community level determinants
• Individual level determinants
Sources of SDOH Data
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• Zip code is more important than genetic code.
Robert Wood Johnson Foundation, 2009
Community Level SDOH Data
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Community Level SDOH Data
• Useful at the system level
• Can enhance performance of predictive models
• Interest to researchers who want to determine the role of
community context in health
• Tools for community generated SDOH
• City Health Dashboard
https://www.cityhealthdashboard.com
• County Health Rankings and Roadmaps
http://www.countyhealthrankings.org/explore-health-
rankings#county-select-38
• CDC Data Set Directory of Social Determinants of Health at
the Local Level
https://www.cdc.gov/dhdsp/docs/data_set_directory.pdf
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Age
Income and Earnings
Race and ethnicity
Ancestry
Labor Force status
School enrollment
Commuting Patterns
Language spoken
Gender
Disability
Marital status
Transportation to work
Educational Attainment
Mobility
Type of work
Employer Type
Nativity
Veterans disability
Fertility
Number of children
Wealth
Food Stamps
Other Income
Well being
Household and Family
Perceived health status
Basic needs, consumer
durables
Housing value
Poverty
Crime
Potential Census Bureau Data
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• Securing appropriate data
• Attributing community data to an individual
• Determining the lowest appropriate level of measurement
• Engaging big data techniques
• Using predictive analytics tools,
• Learning new tools - heat maps
• Looking upstream with available data
Issues Related to Community Level
SDOH
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• Collected through screenings, checklists, or surveys
• Can be embedded into the EHR, or a tablet, or PHR, or on paper
• Vendors have added SDOH screenings into EHRs
– Intimate Partner Violence
– Social Isolation
– Alcohol and Tobacco Use
– Depression
– Financial Resources
– Food, transport and housing insecurity
Individual Level SDOH Data
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• Protocol for Responding to and Assessing Patients’ Assets, risks,
and Experiences (PRAPARE) from the
15 core and 5 supplemental question
Structured data
Administered by a clinician or staff
http://www.nachc.org/research-and-data/prapare/toolkit/
• CMS Accountable Health Communities Health Related Social
Needs Screening Tool
Medicare and Medicaid recipients
Self administered
Covers 5 domains with 8 supplemental domains
https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf
Examples of Individual Level Tools
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• Social Interventions Research and Evaluation Network (SIREN)
Collects, summarizes, and compares tools for adults and
pediatric populations
Has compiled information on the most widely used tools
https://sirenetwork.ucsf.e https://sirenetwork.ucsf.edu/tools-
resources/mmi/screening-tools-comparison/adult-nonspecific
du/about-us
Compilations and Comparisons of SDOH
Tools
AHC
-
Tool
HealthBegi
ns
Health
Leads
MLP
IHELLP
Medicare
Total Health
Assessment
Questionnai
re
NAM
Domains
PRAPARE
WellRx
Your
Current
Life
Situation
iHELP SEEK SWYC We Care
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• Who is the population – Adults? Pediatric?
• Do you need a targeted tool?
Interpersonal Violence screening in pregnant women
Adverse Childhood Experiences (ACE) for children
Homelessness
• Are the tools validated?
• Is there a cost to use the tool?
• Are the assessments and measures standardized and coded for
reuse?
https://loinc.org/sdh/
Issues with Individual SDOH Tools
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Triple S of SDOH Data
• Systematic SDOH collected in all encounters
• Structured SDOH via tools
• Standardized SDOH using datasets to allow for aggregation and
interoperability
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• ICD-10-CM codes included in categories Z55-Z65
Z55 Health literacy (illiteracy, schooling…)
Z56 Employment and unemployment (work environment)
Z57 Occupational exposure (radiation, dust, smoke…)
Z59 Housing and economic circumstances (homeless, inadequate
housing…)
Z60 Social environment (life transitions, living alone…)
Z62 Upbringing (inadequate parental supervision, overprotection…)
Z63 Primary Support Group (family member absence, disappearance,
death, stress…)
Z64 Psychosocial Circumstances (unwanted pregnancy, discord…)
Z65 Other Psychosocial (convictions, imprisonment, crime…)
PRAPARE template uses the Z codes
https://images.magnetmail.net/images/clients/AHA_MCHF/attach/2018/April/valueinitiativeicd10odesdoh0418.p
df
Standards and Coding for SDOH Data -
ICD
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• Social, psychological and behavioral observations
• 80216-5 panel data from:
2015 Health IT Certification Criteria
Patient Health Questionnaire (PHQ-2)
Alcohol Use Disorder Identification Test – Consumption
(AUDIT-C)
Humiliation, Afraid, Risk, and Kick (HARK)
National Health and Nutrition Examination Survey (NHANES)
• 82152-0 panel data from:
Adverse Childhood Events (ACE)
Behavioral Risk Factor Surveillance System (BRFSS)
https://s.details.loinc.org/LOINC/80216-5.html?sections=Comprehensive
Standards and Coding for SDOH Data -
LOINC
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• Transportation
• Uber Health removing transportation as a barrier
https://www.uber.com/newsroom/uber-health/
Creative Responses to SDOH
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• UABSON’s nurse managed PATH clinic
• UABMC Heart Failure Clinic
• Community Food Bank of Central Alabama
• Food Banks as partners in. health promotion
http://www.rootcausecoalition.org/wp-content/uploads/2016/07/Food-Banks-as-
Partners-in-Health-Promotion-FINAL.pdf
Food Insecurity
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• Utah Alliance for Determinants of Health (Intermountain)
https://intermountainhealthcare.org/blogs/topics/transforming-
healthcare/2018/07/new-alliance-seeks-to-address-the-social-
determinants-of-health/
• Baltimore Accountable Health Community – the only health
department to receive a CMMI grant
https://health.baltimorecity.gov/sites/default/files/health/attachments/
Baltimore%20Accountable%20Health%20Community%20Overview.
pdf
Alliances to Address SDOH
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• Integration of SDOH across primary care to transitions workflows
• Creation of communications’ pathways between hospital and home
• Systems approach to managing complex, chronically ill patients
• Relies on tools developed using interoperability standards
• Incorporates claims based risk stratification and an assessment of SDOH
using the Patient-Centered Assessment Method (PCAM)
• PCAM – 12 item Likert scale tool measuring 4 domains: physical and
mental health, social support, health literacy, and engagement with
services
• SDOH incorporated into a reworked informational and clinical workflow
• Operationalized through a collaboration of University of Buffalo SON,
Department of Family Medicine, a RHIO, and a PCMH
(Hewner, Casucci, Sullivan et al, 2017)
Integrating Social Determinants
across Transitions
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• Identify the population and evidence supported purpose
• Determine community or individual level data needs
• If individual is it clinician or patient entered
• Decide if data will be collected as part of a flowsheet, through
portal, or on paper
• Ensure that SDOH data is incorporated and reported
• Use clinical decision support tools (rosters, alerts)
• Identify and create referral database
• Create referral ordering functions
• Use coded, standardized tools
• Create data linkages and closed loops
Optimizing the Collection of SDOH
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• Creating actionable SDOH data is vital
Social determinants referrals
Making a match
Workflow implications
Closed loop reporting – Do we know they got the service?
Start ups are addressing the loop:
NowPow
Healthify
Vendor responses
Optimizing by Closing the Loop
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• Documentation burden
• Implementation is challenging – can you act on the data?
• Clinician engagement
• Support staff engagement
• Requires input from other professionals (SW, OT, PT, etc)
• Operational challenges – where is the ROI?
• No closed loop between care and services
• Patients may not want to answer or want help
• Screenings take time – referrals can be burdensome
• Interpreters may be needed
• Fragmentation of data
• Training, training, training
Lessons Learned
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• Centers for Disease Control and Prevention
https://www.cdc.gov/nchhstp/socialdeterminants/resources.html
• Institute of Medicine
http://nationalacademies.org/HMD/Activities/PublicHealth/Socia
lDeterminantsEHR.aspx
• National Association of Community Health Centers
http://www.nachc.org/research-and-data/prapare/
• Social Interventions Research and Evaluation Network (SIREN)
University of California, San Francisco
https://sirenetwork.ucsf.edu
Resources
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Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN
mwilsoa@uab.edu
@UABSON
UAB School of Nursing
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Questions and Thank You